Provider Demographics
NPI:1346650702
Name:INDIVIDUAL & FAMILY SERVICE LLC
Entity Type:Organization
Organization Name:INDIVIDUAL & FAMILY SERVICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PROFESSIONAL COUNSELOR
Authorized Official - Prefix:
Authorized Official - First Name:CLEATTA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHUMATE-JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MED
Authorized Official - Phone:918-794-2847
Mailing Address - Street 1:2840 E 51ST ST
Mailing Address - Street 2:105
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74105-1744
Mailing Address - Country:US
Mailing Address - Phone:918-794-2847
Mailing Address - Fax:918-747-6601
Practice Address - Street 1:2840 E 51ST ST
Practice Address - Street 2:105
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74105-1744
Practice Address - Country:US
Practice Address - Phone:918-794-2847
Practice Address - Fax:918-747-6601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-06
Last Update Date:2014-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2503101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty